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Objective: To identify factors that influence contraceptive initiation among women with medical conditions., Study Design: We conducted an exploratory cross-sectional survey of women 18-45 years old with medical conditions who received contraception consultation from complex family planning specialists at five University of California Medical Centers from June 2014-June 2015. We asked survey participants about factors that influence their decision of choosing and initiating a contraceptive method, how they accessed family planning specialists and the impact of this consultation on their contraceptive method choice., Results: Among 97 participants, 61 (63%) had one medical condition, 28 (29%) had two medical conditions, and 8 (8%) had three or four medical conditions. A majority of participants initiated long-acting reversible contraceptive methods including an intrauterine device (n = 54, 56%) and the contraceptive implant (n = 17, 18%). The most common reason for initiating contraception was to avoid pregnancy in the immediate future for personal reasons (n = 43, 44%). The most common reason for initiating a particular contraceptive method was safety given their medical condition (n = 19, 20%). After the consultation with the complex family planning specialist, participants commonly reported that the person with the most influence on their contraceptive method choice was the complex family planning specialist (n = 35, 36%) and less commonly the primary care provider (n = 9, 9%) and not at all by a family member or friend (n = 0, 0%)., Conclusion: Women with medical conditions are highly influenced by a complex family planning specialist in regard to their contraceptive options and when receiving such counseling, will often choose highly effective methods., Implications: This study provides insight into contraceptive decision-making among women with medical conditions referred to a complex family planning specialist for contraceptive care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To compare differences in patient-provider communication among patients who, prior to contraceptive counseling, used or did not use a decision support tool ("My Birth Control") which has educational and interactive modules and produces a provider printout with the patient's preferences., Methods: As part of a cluster-randomized trial of the tool in four San Francisco safety net clinics, we collected and thematically analyzed 70 audio recordings of counseling visits (31 pre- and 39 post-tool implementation) from 15 providers randomized to the intervention., Results: Without the tool, most providers began by asking participants what method they were considering and focused counseling on that method or on directing patients towards long-acting reversible contraception; with the tool, most focused on reviewing and discussing multiple methods of interest to the participant as indicated on the printout. Discussion of patients' preferences for specific method features was not observed in pre-implementation recordings but was part of several post-implementation recordings. Several participants explicitly noted they had gained knowledge from the tool., Conclusion: Observed counseling differences suggest the tool may have a positive impact on patient-centeredness of contraceptive counseling, consistent with findings from the main study., Practice Implications: My Birth Control shows potential for improving patient-centeredness in counseling without extensive provider training., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: Barriers to the provision of patient-centered contraceptive counseling include time limitations, frequent misconceptions and misinformation about methods among patients, and the availability of numerous contraceptive options, which increases the complexity of contraceptive decision making. Decision support tools are interventions designed to facilitate quality decision making in preference-sensitive decisions. We evaluated the impact of a contraceptive decision support tool, My Birth Control, on providers' experience with contraceptive counseling., Study Design: We interviewed 15 providers who participated in the intervention arm of a cluster randomized controlled trial of My Birth Control to obtain their impressions of their patients' interactions with the tool. We analyzed the interviews using thematic analysis, compared appointment lengths of patients in each arm (n=749) and assessed provider burnout in each arm (n=28)., Results: Providers reported that incorporating My Birth Control into their practice helped them allocate time more efficiently, enabling them to hone in on patients' areas of interest. They also reported that patients who interacted with the tool appeared more informed about contraception options and features, and took a more active role in method selection. All providers described using the tool as acceptable and feasible, and indicated they would like to incorporate it into their practice. There was no difference in provider burnout scores comparing before and after the trial of My Birth Control., Conclusion: Providers had a positive impression of the impact of My Birth Control on contraceptive counseling, including the quality of counseling, and perceived the tool to be a feasible intervention to use in the clinical setting., Implications: Family planning clinics should consider incorporating My Birth Control into their clinical services as a means of improving contraceptive care and provider experience of counseling., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: In this study we aimed to investigate the content and process of contraceptive counseling surrounding combined hormonal contraceptive (CHC) methods (combined oral contraceptives, the ring, and the patch)., Study Design: We performed a mixed methods analysis of data collected as part of the Patient-Provider Communication about Contraception study, in which reproductive age women and their providers were recruited at several San Francisco Bay Area clinics from 2009-2012. Participants completed pre- and post-visit surveys, and had their visits audio recorded and transcribed. We performed descriptive and bivariate analyses of the entire cohort to examine associations between demographic characteristics and pre-existing method preferences with method selection and counseling content, and coded transcripts of a subset of the sample for salient themes related to content and process of counseling about combined hormonal contraceptive methods using a directed content analysis approach., Results: The overall sample included 342 women, with 152 women (44%) having a preference for a specific CHC prior to their visit, 127 women (37%) had a preference for a non-CHC method, and 63 (18%) having no existing method preference. Of the women who reported preferring a CHC in their pre-visit survey, the majority (72%) chose that method. We found that women were inconsistently counseled about the range of CHC methods. For example, women who had no pre-visit method preference (52%) or who preferred the ring (54%) or the patch (73%) were more likely to receive comprehensive counseling about the three CHC methods than were women who preferred combined oral contraceptives (35%) or non-CHC methods (33%). Providers mentioned the patch the least often, and in qualitative analysis indicated discomfort with prescribing this method. Side effects and benefits of methods, as well as strategies to enhance successful use of the chosen method, were inconsistently discussed. In only 73% of visits in which a woman chose a CHC did the provider assess the patient's ability to use the chosen method correctly, and in 66% of all visits in which women chose a CHC method, providers discussed what to do if she was dissatisfied with the method., Conclusions: Counseling about combined hormonal contraceptive methods often does not include information about all available methods, or comprehensive information about side effects, benefits, or logistics of use. As this counseling can impact patient's satisfaction with and continuation of their chosen method of contraception, future work should focus on designing interventions to improve providers' ability to meet patients' needs., Implications: Short acting hormonal contraception is widely used, but counseling for these methods often neglects key features. Comprehensive counseling about all methods and their individual features can improve contraceptive selection and use., (Published by Elsevier Inc.)

Objective: We developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection., Methods: Drawing upon formative work around women's preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process., Results: Ninety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool's content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement., Conclusion: Our decision support tool appears acceptable to women in the family planning setting., Practice Implications: Formative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Shared decision making (SDM) is a potentially valuable but underexplored approach to contraceptive counseling., Methods: We determined the correlation between patient report of SDM and of whether their provider had a method preference with measures of satisfaction., Results: Women reporting SDM were more likely to be satisfied with counseling than those reporting a provider-driven decision and were more likely to be satisfied with their method than those reporting a patient-driven decision. Patients who felt that the provider had a method preference were less likely to be satisfied with their method., Conclusions: SDM in contraceptive counseling is associated with patient satisfaction., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: Provider self-disclosure (PSD) - defined as providers making statements regarding personal information to patients - has not been well characterized in the context of contraceptive counseling. In this study, we describe the incidence, content and context of contraceptive PSD., Study Design: This mixed methods analysis used data from the Provider-Patient Contraceptive Counseling study, for which 349 family planning patients were recruited from 2009 to 2012 from six clinics in the San Francisco Bay Area. Audio-recordings from their visits were analyzed for the presence or absence of PSD, and those visits with evidence of PSD were analyzed using qualitative methods. The associations of patient and provider demographics and patient satisfaction measures, obtained from survey data, with PSD were analyzed using bivariable and multivariable analyses., Results: Thirty-seven percent of providers showed evidence of PSD during at least one visit, and PSD occurred in 9% of clinic visits. Fifty-four percent of PSD statements were about intrauterine devices. About half of PSD statements occurred prior to the final selection of the contraceptive method and appeared to influence the choice of method. In post-visit surveys, all patients who reported receiving PSD considered it to be appropriate, and patient-reported PSD was not statistically associated with measures of patient satisfaction., Conclusions: This study provides some support for the appropriateness of PSD during family planning encounters, at least as practiced during the sampled visits. Further research could explore whether this counseling strategy has an impact on patients' ability to identify the best contraceptive methods for them., Implications: In this study, PSD did not have a demonstrated negative effect on the provider-patient relationship. In almost half of visits, PSD appeared to influence patients' choice of a method; whether this influence is beneficial needs further research., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We undertook a qualitative analysis informed by grounded theory to explore pregnancy intention and the barriers to contraceptive use as perceived by homeless women with children. Semi-structured interviews (n = 22) were performed in English and in Spanish. The dominant theme emerging from the interviews was a strong desire to avoid pregnancy while homeless. However, few women in our sample used contraception or accessed reproductive health care consistently. There were multiple barriers to using contraception and to accessing reproductive health care services that homeless women reported: (1) inability to prioritize health due to competing demands, (2) shelter-related obstacles and restrictive provider practices that impede access to reproductive health care services and the use of contraception, and (3) change in the power dynamics of sexual relationships while homeless, making women more vulnerable to sexual exploitation. Findings suggest a multifactorial approach is needed to help homeless women use contraception and access reproductive health services.

Objective: To determine Ugandan women's perceptions and knowledge of contraception., Methods: Healthy prepartum women were recruited from a national referral and university teaching hospital to participate in 1 of 5 focus group discussions on contraception. Transcripts were translated and coded by 2 researchers using inductive and deductive methods., Results: Forty-six women participated in the focus group discussions. The major themes that emerged were around family planning as a method to space pregnancies and manage finances, as well as men's roles in decision making regarding contraception. Notable among the many incorrect notions about adverse effects of contraception were fears about cancer and infertility., Conclusion: The results indicate that, among the study group of Ugandan women, decision making regarding family planning involves a complex negotiation among women, partners, and families. Furthermore, pervasive myths may hinder a woman's ability to choose safe and effective contraception. These findings are useful to healthcare providers and the greater public-health community., (© 2013.)

Background: Little is known about what women value in their interactions with family planning providers and in decision making about contraception., Study Design: We conducted semistructured interviews with 42 black, white and Latina patients. Transcripts were coded using modified grounded theory., Results: While women wanted control over the ultimate selection of a method, most also wanted their provider to participate in the decision-making process in a way that emphasized the women's values and preferences. Women desired an intimate, friend-like relationship with their providers and also wanted to receive comprehensive information about options, particularly about side effects. More black and Spanish-speaking Latinas, as compared to whites and English-speaking Latinas, felt that providers should only share their opinion if it is elicited by a patient or if they make their rationale clear to the patient., Conclusion: While, in the absence of medical contraindications, decision making about contraception has often been conceptualized as a woman's autonomous decision, our data indicate that providers of contraceptive counseling can participate in the decision-making process within limits. Differences in preferences seen by race/ethnicity illustrate one example of the importance of individualizing counseling to match women's preferences., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Context: Health care providers may influence patients' choice of contraceptive method, yet little is known about the recommendations they make to their patients., Methods: In 2007-2008, a total of 468 physicians at four family medicine and obstetrics and gynecology meetings were randomly assigned to view one of 18 videos of a patient seeking contraceptive advice; the patients were standardized for most relevant behaviors and characteristics, but differed by race and ethnicity, socioeconomic status and gynecologic history. Participants provided their demographic and practice characteristics and completed a survey about their contraceptive recommendations for the patient. Multivariate logistic regression analyses were conducted to identify associations between physician characteristics and recommendations for specific contraceptive methods., Results: The most frequently recommended methods were the pill (89%) and ring (80%), followed by the levonor-gestrel IUD (64%), patch (56%), injectable (49%) and copper IUD (45%). Oral contraceptives were more likely to be recommended by private practice physicians than by academic physicians (odds ratio, 2.9). Recommendations for the ring were less common among family physicians and those 56 or older than among obstetrician-gynecologists and those 35 or younger (0.6 and 0.3, respectively), and more common among physicians in private practice than among those in academia (2.4). The patch and injectable were more commonly recommended by family physicians than by obstetrician-gynecologists (2.6 and 2.5, respectively). Both IUD types were recommended less often by physicians 36 or older than by younger ones (0.2-0.5)., Discussion: The advice women receive about contraception may vary according to the characteristics of their provider. Research on the reasons for these differences is needed., (Copyright © 2011 by the Guttmacher Institute.)

Objective: To determine the fertility and contraceptive desires of genital fistula patients in eastern Democratic Republic of the Congo (DRC) and to evaluate the impact of contraceptive counseling and its effect on contraceptive knowledge and use., Methods: Group contraceptive counseling was offered to fistula patients at HEAL Africa Hospital between February and May 2010. Fertility desires and contraceptive knowledge were assessed via verbally administered questionnaires before and after counseling, and use of modern contraceptive methods was tracked., Results: Of the 61 participants, 22/34 (64.7%) of those who desired children wanted to wait at least 1 year after repair before attempting pregnancy. Overall, 31/58 (53.4%) women had heard of birth control, although only 15 (24.6%) knew any specific methods, and none had ever used contraception. After counseling, all participants could recall 1 or more methods. Of the 25 participants discharged over the subsequent 3 months, 5 (20.0%) and 3 additional fistula patients selected a modern method of contraception., Conclusion: Desire for contraception and birth spacing among women with fistula is significant. Basic group contraception counseling and access are feasible and lead to increased contraceptive knowledge and use., (Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: Studies suggest that not all patients desire shared decision making, and little is known about decision making around contraception. This study compared decision-making preferences for contraception to preferences for general health among reproductive-aged women., Methods: 257 women receiving abortion care in an urban hospital completed a survey which included questions adapted from the Problem-Solving Decision-Making Scale about their preferences for medical decision making., Results: Women were significantly more likely to desire autonomous decision making about contraception than about their general health care (50% vs. 19%, p<.001). No patient characteristics were associated with contraceptive decision-making preferences. Women with Medicaid insurance were more likely to desire autonomous decision making about contraception than about general health care (51% vs. 17%, p<.001)., Conclusion: Women desire more autonomy in their contraceptive decisions than in their decisions about general health care., Practice Implications: Health care providers should be attentive to the existence of variation in preferences in decision making across health domains. Contraceptive providers should proactively assess decisional preferences to ensure the most appropriate counseling is provided to each individual., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Contraceptive providers have an important influence on women's selection of contraception. Previous studies suggest that clinicians inappropriately limit use of intrauterine contraception (IUC). This study investigated the influence of patients' gynecologic histories on recommendations for IUC and other methods of contraception., Study Design: Videos of standardized patients varying by history of pelvic inflammatory disease (PID) and parity were shown to clinicians at meetings of national medical societies. Participants indicated their contraceptive recommendations for the patient and whether they would have concerns were the patient to use IUC., Results: Five hundred twenty-four providers viewed one video of a standardized patient and completed the survey. Gynecologic history was significantly associated with recommendations for the contraceptive ring, contraceptive patch, and copper IUC. Many clinicians indicated that they had concerns about the use of IUC with respect to risks such as PID, infertility and ectopic pregnancy. Concerns about infertility and pain with use of IUC were related to gynecologic history., Conclusions: Patient gynecologic characteristics affect recommendations for some reversible contraceptive methods. Clinicians continue to have concerns about IUC use despite evidence supporting its safety., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: The underuse of effective contraceptive methods by women at risk for unintended pregnancy is a major factor contributing to the high rate of unintended pregnancy in the United States. As health care providers are important contributors to women's contraceptive use, this study was conducted to assess provider knowledge about contraception., Study Design: Bivariate and multivariate analyses were performed using data collected from a convenience sample of health care providers (physicians, nurse practitioners and physician assistants) at meetings of the professional societies of family medicine and obstetrics and gynecology., Results: Younger providers were more knowledgeable, as were obstetrician/gynecologists, female providers and providers who provide intrauterine contraception in their practice., Conclusions: The lack of consistent and accurate knowledge about contraception among providers has the potential to dramatically affect providers' ability to provide quality contraceptive care for their patients, which could have an impact on their ability to prevent unintended pregnancies., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: This study evaluates the inclusion of sexual and reproductive health (SRH) topics in preclinical US and Canadian medical education., Study Design: Between 2002 and 2005, we sent surveys to the student coordinators of active Medical Students for Choice chapters at 122 US and Canadian medical schools. Students reported on the preclinical curricular inclusion of 50 specific SRH topics in the broad categories of pregnancy, contraception, infertility, elective abortion, ethical and social issues, and other topics., Results: We received 77 completed surveys, for an overall response rate of 63%. Coverage of pregnancy physiology and STIs/HIV was uniformly high. In contrast, inclusion of contraceptive methods and elective abortion procedures greatly varied by subtopic and geographic region. Thirty-three percent of respondents reported no coverage of elective abortion-related topics., Conclusions: Inclusion of contraception and elective abortion in preclinical medical school courses varies widely. As critical components of women's lives and health, we recommend that medical schools work to integrate comprehensive family planning content into their standard curricula.